PROJECT SUMMARY/ABSTRACT Background: According to the North Carolina Division of Public Health, 1,101 people died in 2012 from unintentional poisoning in the state, with 92% of all unintentional poisoning deaths drug or medication related. Medication-Assisted Treatment (MAT) is an evidence-based, safe and effective strategy for decreasing the frequency and quantity of opioid use and reducing the risk of overdose and death. Objective: The core aims for the UNC Extension for Community Healthcare Outcomes for Rural Primary Care Medication Assisted Treatment (UNC ECHO for MAT) demonstration project are to: (1) increase understanding about how known barriers to the implementation of medication-assisted treatment (MAT) in primary care can be overcome, and (2) evaluate strategies to overcome those barriers; while, we simultaneously expand access to MAT in 22 rural and underserved counties, reducing the risk of accidental overdose deaths through a multi- layered provider and practice engagement strategy. Methods: Using a RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) approach and through a mixed methods study design, we will gather data on the number and representativeness of the primary care providers (PCPs) who agree to participate in the waiver and ECHO tele-trainings and tele-case conferences; assess how many actually start prescribing; evaluate the consistency and quality of MAT, fidelity to MAT guidelines/protocols in terms of dosage, refills, complementary patient education/counseling, and because this is a provider-level demonstration project, effectiveness of the intervention will be assessed indirectly using Medicaid and BCBS claims data. The RE-AIM evaluation will be coupled with qualitative interviews to explore RE-AIM issues (e.g., find out why people did or did not agree to participate and/or adopt MAT, what practice-level implementation issues arose, what intended and unintended consequences resulted, why some maintained and others didn't). Potential Impact: Through a multi-layered provider intervention based on the Project ECHO model and practice level engagement activities, we anticipate 150 new PCPs in 22 rural counties will receive the DATA- 2000 waiver training and 75% will go onto provide MAT. By identifying barriers, and implementing strategies to overcome barriers to effective engagement of rural PCPs in the provision of MAT, we will increase the availability of MAT in rural communities and thereby reduce accidental overdose death rates. The impact will be expanded beyond the target counties and providers through dissemination of information about effective rural PCP recruitment and engagement methods and practice resources developed through the project.